How to Write a SOAP Note in Nursing Assignments

SOAP notes are a highly structured way to keep track of how a patient is doing during treatment. This is just one of many ways a health professional could keep track of a patient’s progress. The purpose of these entries in the patient’s medical record is to inform the clinical reasoning process, inform the patient’s care, and communicate information to other providers of care.

What is the Purpose of the SOAP Note Nursing Assignments Paper?

The purpose of a SOAP note in a nursing assignment is to document the care provided to a patient and to communicate important information about the patient’s condition and treatment to other healthcare providers. SOAP notes provide a standardized method of recording patient care, which allows for clear and concise communication among healthcare professionals.

In a nursing assignment, a SOAP note may be used to demonstrate the student’s understanding of the patient’s condition and the steps taken to address it. It may also be used to demonstrate the student’s ability to accurately assess the patient’s condition, develop a plan of care, and document the patient’s progress.

Overall, the purpose of a SOAP note in a nursing assignment is to provide a detailed and organized record of the patient’s care, which can be used to inform future treatment decisions and monitor the patient’s progress.

What Exactly is a SOAP Note?

SOAP notes are a common format for documenting patient care in the healthcare field, including nursing. SOAP stands for Subjective, Objective, Assessment, and Plan. A SOAP note is a method of documentation that records a patient’s care and progress.

Healthcare providers frequently use SOAP notes, according to Podder et al. (2020). Medical professionals also use it as a method for maintaining structured and orderly patient records.

Healthcare providers can use the SOAP note style to better assess, diagnose, and treat patients based on their subjective and objective symptoms. They also facilitate intra- and inter-professional communication among healthcare workers.

SOAP notes are part of a patient’s medical records. As a result, they need to be comprehensive, transparent, and concise.

Dr. Lawrence Weed, a professor at the University of Vermont, is widely considered to be the founder of the SOAP note. The origins of SOAP Notes can be traced back to the 1960s.

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Basic Structure/Outline for SOAP Notes

The basic structure of a SOAP note includes four main sections: Subjective, Objective, Assessment, and Plan. It is structured as follows:

  • Subjective: This section includes information about the patient’s symptoms and complaints as reported by the patient or family member. This can include descriptions of the symptoms, how long the symptoms have been present, and any other relevant details.
  • Objective: This section includes information about the patient’s physical exam and vital signs. This can include findings from the examination, such as the presence of a rash or swelling, as well as measurements such as blood pressure and heart rate.
  • Assessment: This section includes the healthcare provider’s interpretation of the patient’s condition and the diagnosis. This can include a summary of the patient’s symptoms and exam findings, as well as any relevant test results or imaging studies.
  • Plan: This section includes the treatment plan for the patient, including any medications or follow-up visits. This can include specific instructions for the patient, such as how to take a medication or what to do if their symptoms worsen.

Remember to include all relevant information in each section and to use proper spelling and grammar. It is important to keep SOAP notes organized and clear for effective communication with other healthcare providers.

Basic Steps for Effectively Writing a SOAP Note in Nursing

Though every medical professional has their own preferred approach to taking and writing SOAP notes, there are some helpful guidelines you can follow to make sure you include all the relevant information. While we have already gone over the details that should be included in each component of a SOAP note, here are some additional checks and balances to make sure everything is in order.

Writing the Subjective Part of Nursing SOAP Note

The subjective part of a SOAP note should include information about the patient’s symptoms, concerns, and history, as reported by the patient or their caregiver. A patient’s primary concern, symptom, or issue is referred to as the “chief complaint” (CC). The patient may first report one CC when, in fact, there are more. As their clinician, you need to probe deeply to determine which CC best corresponds to their needs.

Here are some tips for writing the subjective part of a nursing SOAP note:

  1. Start by identifying the patient’s chief complaint or reason for seeking medical care.
  2. Record any important information about the patient’s medical history, such as past diagnoses, surgeries, and medications.
  3. Describe the patient’s current symptoms, including their location, duration, and intensity.
  4. Include any information about stress, diet, or activity level that might be affecting the patient’s symptoms.
  5. Use quotes to capture the patient’s own words, as this can help show how they see their condition and what they know about it.

It is important to be thorough and accurate when writing the subjective part of a SOAP note, as it provides important context for the healthcare provider’s assessment and treatment plan. It is also important to use clear, concise language and to follow the format consistently.

Writing the Objective Part of Nursing SOAP Note

The objective part of a SOAP note should include information about the patient’s physical condition and observations made by the healthcare provider, such as vital signs, physical exam findings, and diagnostic test results.

The patient’s subjective account of their CC and the nature of that CC will guide your response and the objective data you gather.

In addition to test or lab results and vital signs, the objective part will include your observations about the patient’s presentation. This pertains to their demeanor, attitude, level of interest, ability to hold a conversation, and general attitude.

Here are some tips for writing the objective part of a nursing SOAP note:

  1. Start by recording the patient’s vital signs, including temperature, pulse, respiratory rate, blood pressure, and oxygen saturation.
  2. Describe any abnormal physical exam findings, such as a rash, swelling, or deformity.
  3. Include the results of any diagnostic tests, like lab tests, X-rays, or imaging studies, that were done.
  4. Write down any important information about the patient’s functional status, such as whether or not they can walk, climb stairs, or do daily tasks.
  5. Don’t use subjective words like “normal” or “abnormal.” Instead, use objective language and say what is being measured or observed.

It is important to be thorough and accurate when writing the objective part of a SOAP note, as it provides important information about the patient’s physical condition that will inform the healthcare provider’s assessment and treatment plan. It is also important to use clear, concise language and to follow the format consistently.

Writing the Assessment Part of Nursing SOAP Note

The assessment part of a SOAP note should include the healthcare provider’s interpretation of the patient’s condition and any diagnoses that have been made.

The assessment part of a SOAP note can be seen as the integration of the patient’s subjective and objective findings. Combining your understanding of the patient’s symptoms with the indicators you’ve already identified can lead to a diagnosis or well-informed treatment plan.

If there are multiple CCs, you may find it helpful to categorize them under the heading “Problems,” along with any relevant evaluations. Clinicians use the assessment section to monitor their patient’s progress over time, so it’s crucial to include as much useful information as you can in a concise format that’s simple to read and use.

Here are some tips for writing the assessment part of a nursing SOAP note:

  1. Start by reviewing the subjective and objective information recorded in the previous sections.
  2. Based on this information, make a list of possible diagnoses that may explain the patient’s symptoms and physical findings.
  3. Consider any relevant risk factors or comorbid conditions that may impact the patient’s health.
  4. Using the available information, make a final diagnosis or list of diagnoses that best explain the patient’s condition.
  5. Include any negative findings that are important, like the lack of certain symptoms or physical exam findings that would support a certain diagnosis.

It is important to be thorough and accurate when writing the assessment part of a SOAP note, as it helps to explain the healthcare provider’s rationale for the treatment plan. It is also important to use clear, concise language and to follow the format consistently.

Writing the Plan Part of Nursing SOAP Note

The plan part of a SOAP note should include the healthcare provider’s plan for treatment and follow-up care for the patient. It’s important to note short-term objectives, the time frame between sessions, and the patient’s desired outcomes.

Using the plan in subsequent sessions will help you see if the patient is getting better and figure out if the plan needs to be changed.

Here are some tips for writing the plan part of a nursing SOAP note:

  1. Start by reviewing the diagnoses made in the assessment section.
  2. Based on the diagnosis, develop a plan for treatment and management of the patient’s condition. This may include medications, therapies, patient education, referrals to specialists, or other interventions.
  3. Think about any possible problems or side effects of the treatment plan and include ways to deal with them.
  4. Set clear goals for the care of the patient and say how they will be measured or assessed.
  5. Include a plan for follow-up care, including scheduled appointments and any self-management tips the patient should use.

It is important to be thorough and specific when writing the plan part of a SOAP note, as this helps to ensure that the patient receives appropriate care and support. It is also important to use clear, concise language and to follow the format consistently.

Sample Soap Note Template Examples

Here is an example of a SOAP note for a nursing assignment:

  • Subjective: The patient is a 32-year-old male with a history of asthma who presents with shortness of breath and wheezing.
  • Objective: Vital signs are within normal limits. Lung sounds are clear.
  • Assessment: The patient’s symptoms are consistent with an asthma flare-up.
  • Plan: Prescribe the patient a rescue inhaler and follow up in 2 days. Educate the patient on the importance of using the inhaler as prescribed and recognizing early signs of an asthma attack.

Here is another example of a SOAP note for a nursing assignment:

  • Subjective: The patient is a 45-year-old female with a history of hypertension and diabetes who presents with complaints of chest pain and shortness of breath. The chest pain is described as a sharp, stabbing sensation located in the left side of the chest and radiating to the left arm. The shortness of breath is described as progressively worsening over the past two days. The patient rates the pain as 8 out of 10 in severity.
  • Objective: Vital signs are as follows: blood pressure 160/100 mmHg, pulse rate 110 bpm, respiratory rate 24 breaths per minute, temperature 98.6°F. Lung sounds are clear. A cardiac exam reveals tachycardia and regular rhythm.
  • Assessment: The patient’s symptoms are consistent with the acute coronary syndrome.
  • Plan: Administer aspirin and order a cardiac enzyme panel and ECG. Administer oxygen via nasal cannula at 2 L/min. Contact the patient’s primary care physician to notify them of the patient’s presentation and potential diagnosis. Follow-up with the patient in 24 hours to assess for any changes in symptoms and to review test results. Educate the patient on the importance of taking their medications as prescribed and recognizing the signs of a potential cardiac event.

Here is another example of a SOAP note for a nursing assignment:

  • Subjective: The patient is a 75-year-old female with a history of hypertension who presents with complaints of fatigue and shortness of breath. The patient reports that she has had these symptoms for the past week and that they have been progressively getting worse.
  • Objective: Vital signs are as follows: blood pressure 182/96 mmHg, heart rate 92 bpm, respiratory rate 20 breaths per minute. Lung sounds are clear. No peripheral edema is present.
  • Assessment: The patient’s symptoms and elevated blood pressure are consistent with uncontrolled hypertension.
  • Plan: Prescribe the patient a new antihypertensive medication and schedule a follow-up appointment in 1 week. Educate the patient on the importance of taking the medication as prescribed and the importance of monitoring her blood pressure. Discuss the need for lifestyle modifications, such as reducing sodium intake and increasing physical activity.

Here is another example of a SOAP note for a nursing assignment:

  • Subjective: The patient is a 75-year-old female with a history of hypertension and type 2 diabetes who presents with fatigue and weakness. She reports that she has been feeling tired and weak for the past week and has noticed a decrease in her appetite.
  • Objective: Vital signs are within normal limits. Heart sounds are regular. The patient appears weak and tired.
  • Assessment: The patient’s symptoms are consistent with uncontrolled diabetes. Laboratory results show a hemoglobin A1c level of 9.5%.
  • Plan: Increase the patient’s insulin dosage and follow up in 1 week. Educate the patient on the importance of proper blood sugar control and the need to monitor blood sugar levels regularly. Recommend a referral to a dietitian for nutritional counseling.

Valuable Tips for Writing a Nursing a SOAP Note Assignment

  1. Use proper formatting: Make sure to follow the standard SOAP note format, with the four main sections (Subjective, Objective, Assessment, and Plan) clearly labeled and in the correct order.
  2. Be concise: Include only relevant information in each section and keep the SOAP note as concise as possible.
  3. Use proper language: Use proper medical terminology and avoid slang or informal language.
  4. Use proper spelling and grammar: It is important to use correct spelling and grammar in order to maintain clear and effective communication with other healthcare providers.
  5. Include all relevant information: Make sure to include all relevant information about the patient’s condition and treatment in the SOAP note.
  6. Keep the SOAP note organized: Use headings and bullet points to keep the SOAP note organized and easy to read.
  7. Use credible sources: If you are including information from sources outside of the patient encounter, make sure to use credible sources such as peer-reviewed articles or guidelines from reputable organizations.

Abbreviations Examples to Use in Writing a Nursing a SOAP Note Assignment

There are many abbreviations that are commonly used in writing SOAP notes and other medical documentation. Here is a list of some commonly used abbreviations in nursing SOAP notes:

  • BP: blood pressure
  • HR: heart rate
  • RR: respiratory rate
  • O2 sat: oxygen saturation
  • Ht: height
  • Wt: weight
  • BSA: body surface area
  • FBS: fasting blood sugar
  • A1c: hemoglobin A1c
  • Hgb: hemoglobin
  • Hct: hematocrit
  • WBC: white blood cell count
  • ANC: absolute neutrophil count
  • INR: international normalized ratio
  • Cr: creatinine
  • GFR: glomerular filtration rate
  • BUN: blood urea nitrogen
  • LFTs: liver function tests
  • CT: computed tomography
  • MRI: magnetic resonance imaging
  • XR: X-ray

It is important to use abbreviations consistently and to spell them out in full the first time they are used in a SOAP note. This ensures that the SOAP note is clear and easy to understand for all healthcare providers.

Bottom Line

An excellent SOAP note maintains brevity, formality, and specificity. Try to stay neutral and not come across as either complimentary or negative. Clarify the language to make sure it conveys the intended meaning (e.g., double-check your pronouns to make sure it is obvious who or what is being referred to).

SOAP notes are used by a wide range of healthcare providers to aid with patient assessment. This includes doctors, counselors, physical therapists, and EMTs. When multiple doctors are caring for the same patient, SOAP notes are essential for communicating progress and coordinating care.

The healthcare industry relies heavily on “SOAP notes” because of their usefulness in separating relevant data from irrelevant details. That’s because it helps doctors figure out what’s going on with a patient quickly and in an orderly fashion.

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